Differentiating Shoulder Versus Cervical Spine Pathology: A Pain in the Neck

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Differentiating Shoulder Versus Cervical Spine
Pathology A Pain in the Neck

• Kern Singh, MD
• Assistant Professor
• Department of Orthopedic Surgery
• Rush University Medical Center
• Attending Spine Surgeon
• Oak Park and Central DuPage Hospital

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Introduction

• Cervical spine and rotator cuff pathology may
  present in very similar clinical patterns.
• Thorough knowledge of spine and shoulder anatomy
  is essential.
• Meticulous physical examination along with simple
  diagnostic studies can make the difference
  between wrong operations!

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So why is this such a pain in the neck?

• 51 year old female librarian
• While at work lifting boxes of books (60lbs)
• Lost balance and slipped
• Felt immediate pain in her neck and shoulder
• Shoulder and C-Spine radiographs - normal

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Simple Anatomy
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Rotator Cuff Anatomy

• The rotator cuff is made up of four muscles and
  their corresponding tendons.
• Supraspinatus
• Infraspinatus
• Subscapularis
• Teres minor
• Originate from the scapula, and together form a
  single tendon unit over the head of the humerus
  named the rotator cuff.

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Rotator Cuff Pathology

• Rotator cuff pathology is most commonly caused by
  extrinsic (outside) causes.
• Traumatic tear from a fall or accident.
• Overuse injuries from repetitive lifting,
  pushing, pulling, or throwing.

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Cervical Spine Anatomy

• Cervical nerve roots (C4-6) innervate the rotator
  cuff muscles.
• Difficult to differentiate because the sensory
  distribution runs from the base of the neck to
  the outer edge of the shoulder.
• Any of these nerves can produce pain in the
  scapula, shoulder, upper/lower arm, and hand.

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So who is best to evaluate this situation?

• Shoulder Surgeon vs Spine Surgeon

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Clinical Symptoms Rotator Cuff versus Cervical
Radiculopathy
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Hmmm.

• The symptoms sounds so similar. What else can I
  do?

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Physical Examination

• The physical exam should be systematic and may
  involve using special maneuvers.
• Specials tests include the
• Neers, Hawkins, and Jobes tests for rotator
  cuff pathology
• Spurlings sign for cervical radiculopathy.

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Neers Test

• Tests for impingement of the rotator cuff tendon.
• The patient is asked to forward flex a fully
  pronated arm.
• The examiner prevents the scapula from moving and
  provides resistance against further forward
  flexion.
• This test will cause pain in patients with cuff
  pathology.

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Hawkins Test

• The Hawkins test is an alternative to the Neers
  test.
• The patient forward-flexes the arm to 90 degrees
  and flexes the elbow to 90 degrees.
• The examiner internally rotates the humerus in
  order to impinge the greater tuberosity against
  the acromion.

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Jobes Test

• Isolates the supraspinatus tendon.
• Abduct the arm to 90 degrees. Arm is angled
  forward 30 degrees. The thumb is then turned
  towards the floor.
• Patient tries to lift against the resistance.
• test is pain along lateral deltoid muscle.

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Spurlings Sign

• Patient should extend the neck and laterally tilt
  the head to the affected side.
• Examiner should apply downward force to the top
  of the head.
• If the test is positive, the re-creation of the
  radicular pain or paresthesia will be evident.

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So what do all these exam findings really tell me?

• Should help to localize pathology

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Back to the original patient

• Further questioning reveals
• Pain that radiates BELOW the elbow into the hand.
• Pain that originates in the NECK.
• Prior history of neck pain

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Now its time to order further imaging

• Obtaining an MRI prior to physical examination
  will lead to an erroneous diagnosis and expensive
  workup for asymptomatic findings.
• The simple provocative maneuvers mentioned
  previously can help differentiate the source of
  pain and provide a more focused treatment
  algorithm.

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So what was done on this patient?
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Clinical Scenario

• Shoulder MRI ordered
• Partial thickness rotator cuff tear
• Patient failed shoulder physical therapy
• Underwent a subacromial decompression, rotator
  cuff debridement, and biceps tenodesis

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And how did she do?
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Patient Never Improved

• Engaged in physical therapy
• Work Hardening
• Functional capacity evaluation at 6 months and
  released with permanent disabilities.

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Patient continues to suffer and decides to see me
with her private insurance.
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On My Examination

• Pain that radiates into her hand
• Specifically her thumb, index, and long fingers
• Pain is reproduced with a Spurlings sign
• Weakness in her brachioradialis and triceps
• Decreased pinprick sensation in the C6 and C7
  dermatome.

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Cervical Spine MRI
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Still maybe the patient isnt reliable

• Its workers comp right?

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The Value of Diagnostic Injections

• If the pathology appears to be coming from the
  shoulder then a subacromial injection.
• If the pathology appears to be coming from the
  cervical spine then a SELECTIVE nerve root
  injections

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I ordered a TFESI C6/C7 Nerve roots

• Patient experienced 100 pain relief

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So what was done?

• Patient underwent a C5-6, C6-7 ACDF with
  Microscope
• She stated that while on the floor for the first
  time in 1 year her pain was gone.
• At 6 months, she was completely fused and
  asymptomatic
• Patient had lost her job and had to find work
  elsewhere

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So lets review what went wrong

• Patient stated she had symptoms originating from
  her neck
• Arm pain went below the elbow
• Patient had nerve specific muscle weakness
• A CERVICAL SPINE MRI should have been ordered!!!!

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Shoulder Versus Neck Treatment Algorithm
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Conclusion

• A patient with diffuse complaints of shoulder
  pain may actually have either shoulder or
  cervical pathology.
• A complete history and physical exam and use
  provocative physical maneuvers, the examiner can
  discover the underlying cause of the symptoms.

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Summary

• A systematic history and physical examination
  will help the treating physician to order
  specific diagnostic studies providing a focused
  treatment algorithm allowing patients to recover
  quicker and return to work and activity sooner.

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Thank You

• Kern Singh, MD
• Attending Spine Surgeon
• Oak Park and Central DuPage Hospital
• Assistant Professor
• Department of Orthopaedic Surgery
• Rush University Medical Center